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随着我国医学事业的发展,医院档案的门类不断增多,除文书、人事档案外,出现了一种新的门类档案——病历档案。这一新的门类档案在医疗护理中显得越来越重要,在临床诊断和治疗患者中发挥着重要的作用。这一新领域的档案越来越为医学界所关注和重视,发表了很多探索性的文章。本人结合医院实际,对病历档案的管理谈点初浅的体会。 一、病历档案的内容 病历档案是医疗部门记载病人健康状况和疾病发生、发展、诊疗过程中形成的具有查考利用保存价值的各种诊疗记录,是医疗临床诊断、科研的重要依据。病历档案的内容包括以下几方面。
With the development of our country’s medical industry, the number of hospital files has been increasing. In addition to documents and personnel files, there has been a new category of files - medical records. This new category of files is becoming more and more important in medical care and plays an important role in clinical diagnosis and treatment of patients. This new area of archives has become more and more important to the medical community and has published many exploratory articles. Combining with the actual situation of the hospital, I personally talked about the management of medical record files. First, the contents of the medical record file Medical record is a medical record of the patient’s health status and the occurrence of disease, development, diagnosis and treatment process formed by the use of the value of the investigation and use of various records of medical records, is an important basis for medical diagnosis, scientific research. The contents of the medical record file include the following aspects.